On the Mode in which External Applications Act on Internal Parts From a dissertation

Lister joined the Royal Medical Society in 1854 and delivered this dissertation to the Society on 21st December 1855. In this dissertation he propounds the idea that there is "sympathy" between external and internal parts such that treatment of internal disease can be adequately treated by applications to the skin such as leeching, cautery and blistering. He illustrates conditions which may be treated by external applications, and attempts to describe the physiological basis of the treatment. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Winter 1965-66, 5(1): 14-20 doi: 10.2218/resmedica.v5i1.446 ON THE MODE IN WHICH EXTERNAL APPLICATIONS ACT ON INTERNAL PARTS F R O M A D IS S E R T A T IO N B Y


JOSEPH LISTER
Lister joined the Royal M edical Society in 1854 and delivered this dissertation to the Society on 21st D ecem ber 1855.In this dis sertation h e propounds the idea that there is "sym pathy" between external and internal parts such that treatment of internal disease can be adequately treated by applications to the skin such as leeching, cautery and blistering.H e illustrates conditions w hich may be treated by external applications, and attem pts to describe the physiological basis of th e treatment.
M any local therapeutic means are employed for the sake of a beneficial influence supposed to be exerted by them upon an organ or tissue placed at a greater or less depth below the surface to which they are applied; as when blood is taken by cupping from the integuments of the chest in pneum onia or when the pre cordial region is blistered in cases of pericarditic effusion.In these days of theory, all are deeply impressed w ith the very just senti m ent expressed by V irg il " F elix sui potuit rerum cognosere causas!"W e are no longer content w ith the suspicion w hich satisfied our ancestors but desire to know the m odus operandi of the remedies w e use.A n d so far is this feeling carried that many are ready to give up w ithout hesitation the m ost tim e honoured m ethods of treatm ent if they appear irreconcilable w ith our present know ledge of Anatom y and Physiology, w hile they are apt to look som ewhat slightingly at the experience by w hich such practice is supported.
N ow it is by no means obvious how external applications act upon deeply seated parts: thus in the form er of the instances above named it is generally believed that the benefit derived from th e local blood letting is greater than could be obtained by venesection of the same am ount, which seems to imply th at the blood is withdrawn in m uch larger proportion from the lung than from other parts of the body; yet it is manifestly preposterous to suppose that cupping glasses, applied over the integum ents of the chest supplied by the intercostal and internal mammary arteries, branches of the aorta, can draw blood directly from the en gorged ramifications of the pulmonary artery, connected with the other side of th e heart.Accordingly some physicians have been led to doubt the special efficacy of local blood letting in inflam mation of deep seated organs.Again in the latter instance, that of blistering the precordial region, none would nowadays be found to believe th at the serum effused under the cuticle had before formed part of the peri cardial accumulation, and it is generally supposed that the blistering, besides causing inflammation of the skin "excites th e vessels" of the pericardium "to increased absorption" as it is said.
But the depth of the pericardium below the surface and the well known superficial action of cantharides forbid the supposition that the inflammation excited in the skin is in any measure or degree propagated by continuity of tissues to the m embrane in question.Similar arguments apply to the case of pleuritic effusion, and an em inent London physician of my acquaintance, influenced I suspect by such con siderations, questions th e advantage of blister ing in either affection.Such doubts cannot be regarded with indifference; if they be well founded it is most im portant for us to know them well and to do our part in relieving suffering hum anity and charitable medical institutions from the useless annoyance and expense of leeches, blisters, etc. in cases of deep seated disease.If on the other hand leeching, blistering and other external means are really as valuable in these cases as our predecessors believed them , then truly it is of the utm ost consequence that we should be aware of the fact both that our patients may have the benefit of their employm ent and th at we ourselves instead of giving ourselves up to the spirit of scepticism which at present too generally per vades the study of our profession may have our tottering faith in medicine strengthened and our respect increased from the hard earned fruits of the labours of our ancestor.T he latter is, I believe, the true state of the case; and the many facts th at bear upon this im portant question only need to be placed in a somewhat clearer light in order th at we may all be con vinced th at it is so.T he following paper has been w ritten with the view of promoting, how ever imperfectly, this m ost desirable object.
T he local means employed by the Physician in the treatm ent of deep seated inflam m ation are the same th at all surgeons use w ith undoubting confidence in affections of parts more superficially placed, e.g.local blood letting, not to mention blistering and issues.
In the cases in which these modes of treat m ent are adopted by the surgeon, the parts affected are commonly within reach of sight or manipulation, and he is therefore able to trace their effects with precision.H ence the reason for the confidence with which these remedies are regarded in surgical complaints, while at the same tim e the proximity of the organ affected to the surface acted upon pre vents the risk of the theoretical objection that may be raised against the use of the same means for disease of more deeply seated organs.Yet when these surgical cases are more strictly scrutinized we shall find th at similar difficulties present themselves in explaining the modus operandi of local treatm ent, even when the affected organs are comparatively superficial.Thus when the testicle is fom ented in cases of acute orchitis it appears at first sight as if the application were made directly to the affected organ.Yet on reflection it will appear th at it is not the testicle itself th a t is warmed and moistened with a hot and wet flannel b u t only the superficial part of the integum ent.T he cuticle no doubt has its tem perature raised on each fresh application of the form entation and also imbibes m oisture and becomes swollen and opaque in doing so, b u t the free circulation of blood through the rich capillary network of the dermis m ust keep the most superficial parts of the cuticle at a tem perature scarcely higher than th at of the blood and also constantly rectify any material differences of chemical composition which the absorption of water into the intercapillary spaces would tend to produce.Still less can we suppose the subcutaneous tissue to be directly altered in tem perature or hum idity under the circumstances in question.Hence even in this apparent example of im m ed iate application of fom entation to the affected part we see that its direct action upon the organ inflamed is out of the question and the very same difficulty meets us in the explaining of its mode of action as if the testicle had been placed some inches below the surface of the body -and yet no practical surgeon will be found to question the beneficial influence of fom entation in orchitis.Again when a blister is applied on the knee in dropsy of th e joint or chronic sinovitis we have no reason to suppose th at the inflam m ation excited by it extends to th e sinovial membrane.W e know th a t if a blister is applied in th e same situation for the remedy of enlarged bursa, th e knee joint remains so far as can be judged quite unaffected, as inflam m ation even to a small degree excited in the synovial m em brane would manifest itself by effusion into the joint which is not observed in these cases.W herever a blister is applied upon the integum ent then this appears as a general rule th e only part affected by it; the subcutaneous tissue retaining its usual lax character so th at th e skin can be moved freely backwards and forwards upon subjacent parts; still less reason is there for supposing th at the inflam m ation excited by the blister passes still more deeply through th e dense fibrous tissues intervening between th e superficial fascia and the synovial membrane.
H ere then the difficulty of explaining the absorption of th e fluid in the joint under the influence of th e blister is of exactly th e same nature as that which should have alluded in the case of precorditic effusion.Y et nothing can be more certain than the fact th at the absorp tion is so induced in the former case.A patient with "Hydrops articuli" may have been confined to bed for weeks with the part carefully band aged w ithout any dim inution in the bulk of the fluid.In such a case the surgeon orders a blister with almost absolute certainty that the speedy removal of the liquid will be the result.
In this case as in that of the fomented testicle the surgeon has the affected part im mediately under observation and no theoretical difficulties in explaining the modus operandi can possibly shake his faith in the efficacy of these means in such cases.
But the surgeon too has not infrequently to deal with disease m ore deeply seated, and there fore, no less than in th e cases just m entioned, occasionally meets with facts quite conclusive in proof of the efficacy of local means.Few surgeons, I imagine, will doubt the beneficial influence so produced upon acute iritis by cupping the temples; yet th e idea of direct withdrawal of blood from the inflamed organ as a mechanical consequence of the action of cupping glasses upon th e integum ent is scarcely as absurd than in the case or pneumonia; the eye-ball, with the exception of the ocular con junctiva, being supplied by the ophthalm ic artery a branch of the internal carotid, while the skin of the face receives its blood from branches of the external carotid.As this is a very illustrative case of local blood letting I may m ention a striking example of it which on a patient under my own observation -a man of syphilitic diatheses under the care of Dr. W alsh of University College Hospital, London, im prudently left his bed in a season day similar to the present to look out of his window at a game of snowballing that was going on in the street, and in the course of a few hours the left eye was affected with severe inflammation.The iris became discoloured, greatly contracted and irregular; lymph appeared at the pupillary margin, the sclerotic was the seat of intense pink infection, the vision of th at eye became misty and he experienced severe pain in the parts of the face surrounding the orbit.It fell to my lot as Dr. W alsh's assistant to deal with this very serious attack.As the m an's general health was rather low I om itted general blood letting and proceeded to cup the temple.N o sooner had the first glass been applied and had drawn up the yet unscarified integum ent as a red hemi-spherical mass, than the patient to my surprise exclaimed th at his vision was m uch clearer and th at his pain was greatly diminished; and though I could hardly believe my eyes the sclerotic infection appeared decidely less.I proceeded to take a few ounces of blood as I had intended and from this tim e forth the inflam m ation which had before been so rapidly advancing steadily abated and in the course of the same afternoon the pupil became much larger and more regular.T he patient also took calomel and opium to which the favourable progress of the case m ust still in part be attri buted; b u t in the unequivocal effects of the first cupping glass in the deep parts of the eye we have an extremely striking instance of the bene ficial influence of this m ethod on the acute stage of inflam m ation in a part almost wholly unconnected as regards direct vascular com munication with the integum ents to which it was applied.T he blood was drawn up in abundance into the soft parts included in the cupping glass; at the same tim e the sclerotic vessels grew comparatively pale, in other words came to contain less blood but, as before observed, anatomy forbids us to suppose th at the blood was drawn mechanically from the scler otic in so great a proportion as from any part supplied by the external carotid.There again the superior opportunities of the surgeon in having to deal with a disease which he could sec enabled him to combine objective with sub jective symptoms as to exclude all doubt regard ing the fact of the benefit derived from a means of treatment which the physician, less favoured in consequence of the obscure position of the parts he treats, may be led to doubt altogether.
As another instance of palpable advantage witnessed in surgical practice from the use of external application for disorders of deeply seated parts I would direct attention to the efficacy of the actual cautery of some severe cases of spinal disease: and I will select one particularly striking case of which an account will be found in detail in the monthly Journal for August, 1854.A man, 27 years old, had been for 18 months affected with disease of the upper cervical vertebrae which had been steadily advancing in spite of treatment till his admission into the Royal Infirmary of the 20th of June 1854."His countenance wore a peculiar expression of mingled suffering and appre hension'' as Mr. Syme expressed it.He com plained of severe pain in the head and neck, aggravated by any sudden movement so that this was a great constraint about all his actions.
Bust of Lord Lister, by Brock, in the Royal College of Surgeons of England, (by kind permission Guthrie, D. (1949), Lord Lister, Edinburgh : Livingstone).
H e always kept his head bolt upright except when in bed and could neither lie down nor sit up without supporting his head with his hands: he never turned his head without the rest of his body.There was great swelling of the upper part of the neck, and he could only open his mouth a little way: deglutition was extremely difficult and a remarkable prominence of the bodies of the upper cervical vertebrae was to be felt in the pharynx.On the day after his admission M r.Syme applied the actual cautery over the spinous processes of the upper cervical vertebrae.N ext day he found less pain on moving the head and in 2 or 3 days his counten ance assumed a cheerful aspect." A steady improvement" says the report, " has since taken p lace in his symptoms and at the present time (July 15th) he has no pain whatever when he sits at rest and can also use strong and active exertion without uneasiness, and no longer re quires to support his head in lying down or rising.H e can turn his head round quite freely and look up at the ceiling and it is only in sudden movements of the neck that he feels any pain at all.T h e swelling in the neck has greatly subsided and he can open his jaws wide and swallow with comparative facility.T he sore on the neck is almost healed and he talks of leaving the hospital in a few days as cured.W hen we consider how far removed the bodies of the cervical vertebrae are from the integu ments of the back of the neck, and further that the actual cautery produces by its direct action only a very superficial effect, as complete proof as need be desired of the beneficial influence of an external agent upon severe organic disease in a part far beyond the range of its immediate action is obtained.
Facts scarcely less striking might be drawn from the practice of Physic but as we have seen the question of their modus operandi is essent ially the same as in that of Surgery and I will for the present content myself with the illustra tions already brought from the latter sources and proceed to the discussion, imperfect as it must be, of the Theory of the action of these external applications.
First I would remark that the consideration of the effects of cupping of the inflamed iris, not to mention other less conclusive instances, shows that the explanation of the action of this group of remedies must not be sought in the arrangement and connections of the blood vessels.If community of vascular supply were the cause of the influence of external agents over internal organs, we should expect to find this most strikingly illustrated in the case of 18 local abstraction of blood; but we have seen that in the iris, as in the lung, it is anatomically absurd to suppose that the withdrawal of blood from the surface to which cupping glasses or leeches are applied can produce any direct drain from the vessels in the affected part, inasmuch as the internal organs and the surface are supplied by branches of widely differing trunks.T h e only other great means of mutual fun ctional connection between one part and an other with which we are acquainted is the nervous system: and it is therefore to this source that we must look for the unravelling of the mystery we are considering.
Imperfect as our knowledge of the Anatomy and Physiology of the nervous system is, we yet know enough of its laws of action to see that it is through the medium of this great bond between the various component parts of the frame, that the effects in question are produced.And now I would wish to direct attention briefly to the sympathetic relations which exist through the agency of the nervous system between one part of the body and another; and more especially between internal organs and the surface placed over or in vicinity of them.This great law is manifested partly in sympathy of sensation; the external surface is richly supplied with sensory nerves while the internal organs have very little sensibility of their own.W e see an obvious final cause for this.T h e surface is that part of the body which is brought into contact with the objects of the external world and requires sensibility to appreciate their presence and influences; and again any disturb ances produced by these foreign bodies can be more readily rectified when the attention of the mind has been drawn to them.Hence both for the purpose of appreciating the qualities of these foreign bodies and rectifying the disturb ances which they may create, acute sensibility is requisite in the integument.In both these respects however, the reverse obtains with internal organs.T h ey are not, generally speaking, exposed to contact with the external world and also it is less necessary for the attention of the mind to be directed to their derangements because their inaccessible position makes it impossible to apply direct means to rectify such disorders.It would have been a cruelty, if it may be said with reverence, to have made the intestinal canal as sensible as the skin so that the mind should have been constantly conscious of irregularities of form or surfaces of the materials passing along it, perceiving sensations like those of painful friction or itchings of the skin, while at the same time the hand could not be applied to remove or diminish an un wieldy mass or to rub away the sense of itching.B ut though internal organs cannot, as a general rule, be reached directly by human means, yet it would appear as if the Creator had defined that their derangements should be, though but to a limited extent, under the control of treatment.A s this can be effected only by indirect means it has been arranged that some part of the surface, generally that lying most nearly over it, shall be placed in sympathetic relations with the organ within so that agents acting on this portion of the integument may produce an influence upon the organ.And in order that mankind may be directed to this indirect mode of treatment it is so planned that the portion of the surface that is in sympathy with the organ for curative purposes shall also sympathise with it in sensation; shall, as it were, feel for it.Thus where the intestines are undergoing contraction beyond the limits of health, the hand is instinc tively placed upon the surface of the abdomen.W h o has not felt the soothing influence of the most superficial friction of the integument in intestinal colic?
In the same case Nature tells even the savage to apply warm applications to the skin of the abdomen and a correspondent from a Hospital in the Dardenelles tells me that there, where diarrhoea is very prevalent, the natives wind an astonishing number of yards of cloth round their, bellies to counteract this tendency of the climate.Again to take the respiratory organs.How remarkable is the tenderness of the skin frequently present over the apex of a tuberculous lung!And how plainly does Nature tell us to avoid and guard against the exposure of the chest and throat when the lungs or bronchial tubes are inflamed.So too when the iris and sclerotic are attacked with inflammation it is not the eye but the integument of the face in its vicinity that is painful, and the headache which results from congestion or inflammation of the brain is commonly quite indistinguish able; to the patient from the painful sensation produced by neuralgia of the nerves of the scalp.Lastly I would allude to the pain in the penis and perineum in cases of stones in the bladder.W ere the pain felt in the organ that is the seat of the abnormal concretion it would be indistinquishable, at least to the non-professional man, from colic of parts of the intestines in the same situation; but as matters are arranged the infant affected with calculus at once draws the attention of his parents to the urinary organs by his energetic demonstrations of the uneasi ness which he experiences in the external parts.
Along with this sympathy of sensation, we see frequent proof of sympathy of Physiological action.
In the case of the respiratory organs the whole integument is more or less in sympathy with them, but the anterior part of the thorax and the soles of the feet more especially and the deep insipration that occurs when the body is plunged into cold water and the first breath excited in the newborn infant by contact of the surface of the body with the external air, are instances of this sympathetic physiological action.Another striking example of it is one familiar to every Accoucheur, who, if the uterus remains relaxed after labour producing haemorr hage applies cold cloths to the vulva or lower part of the abdomen with the confident expect ation that the uterus will at once contract into a firm globe.It is of course not necessary to point out that the cold applied to the vulva cannot possibly produce any reduction of temperature in the womb.I will content myself with one other instance of this sympathetic Physiological action, illustrative once more of the relations that exist between the integuments of the face and the iris, viz. the dilation of the pupil induced by extracts of Belladonna smeared upon the brow and lids.This dilation is clearly due to contraction of the dilating fibres of the pupil.W hen Belladonna acts unusually freely or when a strong solution of its active principle has been applied to the conjunctiva, the dilation far exceeds anything that could be accounted for by supposing the sphincter pupillae relaxed.I remember seeing this effect very strikingly in a child with congenital cataract to whose eye I applied solution of sulphate of atropine pre paratory to dividing the lens, with the effect of making the pupil almost equal in diameter to the cornea so that not only the whole exposed part of the anterior surface of the lens but the black inner margin of the ciliary body was brought into view.W harton Jones has made the curious observation that while all other saline solutions tried by him produced in the arteries of the frogs web constriction followed after a few seconds by dilatation or else dilat ation without any visible interval of constriction, solutions of atropine caused a gradual and permanent constriction of the arteries taking place in about the same time and lasting about as long as the dilatation of the iris when the solution is applied to the human eye.Hence it would appear probable that the Bella donna, when applied to the surface of the eyelids, not only causes contraction of the muscular fibres-of the muscles of the skin, b u t at th e sam e tim e contraction of the dilator p u pillae by sym pathy.T h is view of the phenom ena is dem onstrated b y the beauti fu l experim ent of Bernard upon the sym pathetic nerve in the neck, the division o f which (for instance in th e cat) produces turgiscence o f the vessels o f the ear and face generally, and contraction of the pupil of the side operated on; the dilator pupillae and the constricting fibres of the vessels of the integum ent being together relaxed so that the sphincter pupillae acts w ith out antagonism and the relaxed arteries yield to the distending force o f the heart; and that this explanation is the correct one is proved m ost striking b y the converse experim ent of stim ulating the sym pathetic by galvanism when the pupil becom es at once enorm ously dilated and the vessels o f the ear, previously engorged, becom e invisible.T h e dilators pupillae and constricting fibres o f the arteries are both together m ade to contract by the stimulus applied to th e sym pathetic, w hich is thus proved to have dom inion over both, w hile the third cerebral nerve is known to preside over the sphincter pupillae.
I have dw elt thus fully upon this last exam ple because the case of the iris is very illustrative in m ore ways than one.T h u s : 1. T h e distribution of the blood vessels proves, as we have seen, that they are not the m edium o f sym pathy between the surface of th e face and the iris.
2. T h e tem poral and supra-and infra orbital pain of iritis shows that the soft parts of th e face around the orbit sym pathise in sensa tion w ith affections o f the iris.
3. T h e action of Belladonna, as explained by the observations of Jones and the experim ents of Bernard, show a sym pathy in physiological action between the same parts and further appear to prove the im portant fact that this sym pathy o f Physiological action takes place through the m edium of the sym pathetic.
4. T h e effect of the cupping glass above detailed shows that along w ith the sym pathy of sensation and physiological action is found a clear exam ple o f the influence produced upon an internal organ by one o f the m ost disputed though m ost celebrated external therapeutic means.
Diseased action is but a m odification of the process of health and accordingly, while an internal organ and the surface over it sym pathise in physiological action there are no m ore strik ing exam ples o f sym pathy than those in which deeply seated parts becom e affected with disease in consequence o f external applications.T h u s if a person sits long upon a cold stone he w ill very probably be attacked w ith inflam m ation in or around the prostate gland, or if the subject be a fem ale an attack o f endom etritis m ay ensue, the latter case being strictly parallel w ith the physiological action lately attended to of the contraction of the uterus under the influence o f cold applied to the same region.A gain while the sudden application of cold to th e chest or soles of th e feet induces sighing inspiration, the sam e agent in long continued action on the same part of the surface is apt to induce inflam m ation o f the mucous m em brane of the bronchi.It is need less to m ultiply instances o f facts so fam iliar and I would only now observe that where we see inflam m ation o f an internal organ thus readily induced through the m edium o f the nervous system by the action o f cold upon the surface over it, it appears but natural that agents of a different or opposite nature such as heat, m ay be effectual in curing inflam m ation where operating upon the same parts o f the surface; in other words where the external surface sym pathises w ith the internal organs in causing disease, so under other circum stances it m ay sym pathise w ith it therapeutically.A ccord ingly there is no m ore effectual rem edy for a bronchitis caused by exposure of the back to cold than a hot pediluy ium w hile the hot hip bath is no less beneficial in prostatitis.
From these considerations o f the laws of sym pathy, we have no difficulty in under standing in a general way how external thera peutic m eans m ay produce an effect on parts deeply seated.
I cannot bu t feel that in this paper I have dealt very im perfectly with a subject which though intensely interesting is extrem ely diffi cult.F o r the accuracy o f the facts m entioned I can vouch, and I feel also confident o f the truth of the general theory that it is through sym pathy, in other words through the nervous system, that the external therapeutic applica tion, to which I have specially alluded produce their beneficial effects upon parts w ithin.W ith regard to the m ore intim ate application o f this theory, to these several m ethods in particular, I express m yself w ith greater hesitation, and feel that it is at present in but a crude form .
If however the object which I proposed to m yself has been in any degree attained, if the facts bearing upon this im portant subject have been placed in a clearer light, and if the con fidence o f any o f our m em bers in the use of these m eans of treatm ent has been strengthened I shall feel m yself deeply rewarded.